Healthcare Provider Details

I. General information

NPI: 1679630420
Provider Name (Legal Business Name): VIVIANA URBAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LAKEFOREST BLVD STE 101B
GAITHERSBURG MD
20877-2626
US

IV. Provider business mailing address

101 LAKEFOREST BLVD STE 101B
GAITHERSBURG MD
20877-2626
US

V. Phone/Fax

Practice location:
  • Phone: 301-869-1170
  • Fax: 301-869-0569
Mailing address:
  • Phone: 301-869-1170
  • Fax: 301-869-0569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10446
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: